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Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
https://doi.org/10.1007/s00127-022-02345-4
REVIEW
Continuum beliefs ofmental illness: asystematic review ofmeasures
S.Tomczyk1 · S.Schlick1· T.Gansler1· T.McLaren1 · H.Muehlan1 · L.‑J.Peter2 · G.Schomerus2,3 ·
S.Schmidt1
Received: 17 February 2022 / Accepted: 19 July 2022 / Published online: 5 August 2022
© The Author(s) 2022
Abstract
Purpose The continuum of mental health/illness has been subject to scientific debate for decades. While current research
indicates that continuum belief interventions can reduce mental health stigma and improve treatment seeking in affected
populations, no study has yet systematically examined measures of continuum beliefs.
Methods This preregistered systematic review summarizes measures of continuum beliefs. Following the PRISMA state-
ment, three scientific databases (PubMed, PsycInfo and PsycArticles via EBSCOhost, Web of Science) are searched, instru-
ments are described and discussed regarding their scope, and methodological quality.
Results Overall, 7351 records were identified, with 35 studies reporting relevant findings on 11 measures. Most studies
examined general population samples and used vignette-based measures. Schizophrenia and depression were most com-
monly examined, few studies focused on dementia, ADHD, OCD, eating disorders, and problematic alcohol use, or compared
continuum beliefs across disorders. Validity was very good for most measures, but reliability was rarely tested. Measures
mostly assessed beliefs in the normality of mental health symptoms or the normality of persons with such symptoms but
rarely nosological aspects (i.e., categorical v continuous conceptualization of mental disorders).
Conclusions Current research provides psychometrically sound instruments to examine continuum beliefs for a variety of
mental disorders. While studies suggest utility for general population samples and mental health professionals, more research
is necessary to corroborate findings, for instance, regarding age (e.g., in adolescents), gender, or type of mental disorder.
Future research should also compare self-report ratings, and vignette-based measures, include measures of nosological
concepts to fully grasp the continuum concept of mental illness.
Preregistration PROSPERO: CRD42019123606.
Keywords Mental health· Public health· Systematic review· Stereotyping· Continuum· Assessment
Introduction
The nosological concept of mental disorders has been subject
to long-standing discussions. To date, there is no undisputable
consensus on their categorical or dimensional nature, although
developments of the DSM 5 [1] as well as comprehensive
literature seem to favor continuous measures of psychopa-
thology which furthers a dimensional understanding [2, 3].
Schizophrenia, for example, is described along the prone-
ness–persistence–impairment continuum describing psychotic
and subsyndromal experiences among the general population
with only a small proportion reporting persistent symptoms
that may lead to an impairment [4, 5]. This concept has impli-
cations for prevention, diagnosis and treatment, as it informs
researchers, policymakers and practitioners alike. For example,
a continuum model of schizophrenia emphasizes the need for
selective prevention in at-risk groups [6], and identifies sub-
groups with persistent symptoms for personalized treatment
purposes. It also points to groups with subsyndromal experi-
ences as target groups for early prevention [7]. A categorical
understanding of schizophrenia, on the other hand, facilitates
stigmatizing attitudes, because it allows a clear distinction of
* S. Tomczyk
samuel.tomczyk@uni-greifswald.de
1 Department Health andPrevention, Institute ofPsychology,
University ofGreifswald, Robert-Blum-Straße 13,
17489Greifswald, Germany
2 Department ofPsychiatry andPsychotherapy, Medical
Faculty, Leipzig University, Leipzig, Germany
3 Department ofPsychiatry andPsychotherapy, University
ofLeipzig Medical Center, Leipzig, Germany
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2 Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
1 3
social groups, that is people with and without schizophrenia
[8]. It should be noted, however, that other researchers criticize
such a continuum model from a methodological perspective
[9, 10]. Linscott and van Os [9], for example, point to meth-
odological flaws and challenges of the conception of continua
that might overshadow categorically derived findings, such as
latent classes. A similar debate between categorical and con-
tinuous conceptualizations can be seen for eating disorders
[11–13], obsessive–compulsive disorder [14], generalized anx-
iety disorder [15], depression [16, 17], and at-risk substance
use [18, 19] or gambling [20]. This debate is not limited to
the scientific community but it also affects patients and the
public. Previous research shows that the public perception of
mental illness as a categorical construct is connected to public
stigma [21, 22] and mental health stigma is recognized as a
barrier to treatment seeking [23–29]. It is also linked to nega-
tive psychosocial outcomes, for example, lower self-esteem
and self-efficacy and poor quality of life [30–34]. Conversely,
a continuum model of mental illness is related to more positive
mental health outcomes [35], and lower stigmatizing attitudes.
Therefore, promoting continuum beliefs to the public might be
a promising approach to reducing public stigma [36].
In this manner, Angermeyer and Schulze [21] describe
two core strategies of public communication in line with
either categorical beliefs (i.e., medicalization) or continuum
beliefs (i.e., normalization). The first strategy encompasses
medical treatments of individuals with distinct disorders,
such as schizophrenia, and is more prominent among medi-
cal professionals and connected to biomedical causal beliefs
of mental disorders [37–39]. The second strategy sees psy-
chiatric symptoms as a normal experience but connects men-
tal disorders to an increased level of stress and insufficient
coping resources. It is more prominent among non-medical
health care workers as well as support groups, and it is more
strongly connected to psychosocial causal beliefs [37, 38].
In spite of their potential for public mental health and social
psychiatry, for instance, by reducing stigmatizing attitudes
and thus lowering the barrier to entry into treatment no study
has systematically reviewed and summarized measures for
continuum beliefs regarding mental health and mental ill-
ness, which makes it difficult to assess their validity and
utility. For instance, an experienced-based measure might
be more valid for clinical samples but less applicable to gen-
eral population samples, whereas a vignette-based measure
might be more applicable but also more strongly affected
by bias (e.g., gender bias in case of gendered vignettes).
Therefore, this systematic review aims to review and assess
previously utilized measures for continuum beliefs to har-
monize research efforts and answer the following questions.
(1) What are the characteristics of existing continuum
belief instruments (e.g., country of origin, setting/target
group, examined disorders, mode of administration)?
(2) What are the psychometric properties of continuum
belief measures?
(3) Which areas of the continuum of mental health and
mental illness are covered by continuum belief meas-
ures?
Method
This systematic review was conducted in accordance with
the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) Statement [40] and is registered
with the PROSPERO registry (https:// www. crd. york. ac. uk/
prosp ero; CRD42019123606). Three scientific databases
(PubMed, PsycInfo and PsycArticles via EBSCOhost, Web
of Science) were searched for peer-reviewed articles on
continuum beliefs that were published before June 2022.
The search was performed in line with a review and meta-
analysis on the association between continuum beliefs and
mental health stigma [36]; therefore, initial database search
and abstract and title screening was similar in this study,
but eligibility criteria differed between studies. Search terms
comprised continuum AND stigma AND mental health OR
mental illness, search strategies are presented in Peter etal.
[36]. In addition, reference lists of included studies were
checked to identify additional eligible studies.
Eligibility criteria
Eligibility criteria were described in accordance with the
PICO process [41]:
Population: Human beings from the general population
without any age restrictions.
Intervention: Studies that investigate continuum beliefs
were included, either as observational or interventional stud-
ies. Continuum beliefs refer to the nosological concept of
mental illness, either as a general, transdiagnostic concept
of continuity of mental illness/mental health problems or as
a specific concept for distinct mental disorders. Other forms
of continua, such as the continuum of care [42] or the dual-
continua model of mental health and mental illness [43–45],
were not included, because they represent broader concepts
within psychiatric and psychological research regarding
health care structures as well as psychological functioning,
which transcend the current research question that focuses
on the conceptualization of mental disorders.
Comparison: Experimental as well as observational quan-
titative studies were included; therefore, there was no restric-
tion regarding a potential control group.
Outcome: Studies should measure continuum beliefs,
either as a predictor, an intermediary variable, or as an
outcome.
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3Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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Studies were not limited to a particular design (e.g.,
experimental studies or observational cohort studies) or
method (e.g., quantitative data assessment). Finally, the
search was limited to studies published in English, German,
French, or Polish. Titles and abstracts of identified studies
were screened by the first and second author and full texts
were obtained of potentially relevant studies. Full texts were
then screened against eligibility criteria independently by
the first and second author. Differences were discussed with
the third author and solved by mutual agreement to include
or exclude studies.
Data extraction, synthesis, andanalysis
The first and second author independently extracted data on
authors, date of publication, study design, sample, meas-
ures and psychometric properties (if reported in the original
studies). The first and third author then independently rated
dimensions of methodological quality and psychometric
properties of the measures following the reporting guide-
lines proposed by Bennett etal. [46] to compare measures.
The following dimensions were examined: readability (avail-
ability and length of the measure), cultural translation (avail-
ability in multiple (target) languages), respondent burden
(over/under 60 items), content validity (theoretical founda-
tion and expert consultation), criterion validity (correlation
with external criteria), construct validity (correlation with
related/non-related constructs), internal consistency (Cron-
bach’s alpha below/above 0.70), inter-rater reliability (agree-
ment between different raters), intra-rater reliability (agree-
ment within one rater), test–retest reliability (significant
test–retest correlation across at least two timepoints), floor
or ceiling effects, and responsiveness (successful manipula-
tion check). The definitions are also listed in the table notes
of Table3, but a concise definition of these aspects can be
found elsewhere [47]. Differences in ratings or extracted
information were discussed and solved with the second
author. The narrative synthesis reports identified measures
of continuum beliefs, their assessment method, their content
as well as a rating of their methodological quality. For each
study, design, sample size and composition, and country of
origin are also reported.
Results
The initial database search resulted in 7351 records (Pub-
Med: 3197, Web of Science: 2209, EBSCOhost: 1945), with
73 records being additionally identified from reference lists
of potentially relevant studies. After removing duplicates,
7120 records remained. A screening of titles and abstracts
lead to an exclusion of 6995 records. Finally, 125 full texts
were assessed for eligibility, wherefrom 90 studies were
excluded, leading to a sample of 35 studies for the synthesis
(see Fig.1).
The excluded studies did not assess mental health/illness
but other aspects, such as the continuum of care; they did
not provide measures (e.g., editorials or theoretical work) or
they were based on other concepts of a continuum such as
the dual continua model [43, 45] that refer to psychological
functioning (i.e., the intersection of mental wellbeing and
mental health/illness) rather than nosological concepts of
mental health/illness.
Study description
The included studies [22, 48–81] investigated continuum
beliefs regarding multiple mental disorders (more than one
disorder per study in 15 out of 35 studies). Most studies
were conducted in Germany (n = 14), followed by the United
States of America (n = 10), Australia, Canada, France, and
Singapore (n = 2) as well as United Kingdom, Ireland and
the Netherlands (n = 1). An overview of included studies is
given in Table1.
Overall, most studies focused on schizophrenia (n = 23)
or depression (n = 20), followed by alcohol use disorder or
addiction (n = 5), OCD (n = 3), and dementia (n = 2). One
study each measured continuum beliefs regarding ADHD,
social anxiety disorder/generalized anxiety disorder, eating
Fig. 1 PRISMA flow diagram
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4 Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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Table 1 Overview of included studies measuring continuum beliefs (n = 35)
No Study Design Sample Population Country Measure No. of items Examined disor-
ders
Method Response scale
1 Angermeyer etal.
(2015)
Cross-sectional
(online)
n = 1600;
16–65years;
50% male
General population
(representative)
France Belief in a contin-
uum of symptom
experience
1 Depression;
schizophrenia
Vignette Likert
(1–5)
2 Bahlmann etal.
(2015)
Cross-sectional
(same as no. 20)
n = 3642;
> 18years
General population
(representative)
Germany Belief in a contin-
uum of symptom
experience
1 Depression; schiz-
ophrenia; alcohol
use disorder
Vignette Likert
(1–5)
3 Buckwitz etal.
(2021)
Online experiment n = 478;
mean
age = 34.1years;
59% male
MTurk sample USA Belief in a contin-
uum of symptom
experience
3 Depression Rating Likert
(1–5)
4 Buckwitz etal.
(2022)
Online experiment
(same as no. 3)
n = 304;
mean
age = 34.1years;
59% male
MTurk sample USA Belief in a contin-
uum of symptom
experience
3 Depression Rating Likert
(1–5)
5 Cassidy etal.
(2020)
Online experiment n = 398;
18–75years;
mean
age = 36.76years;
50.3% male
MTurk sample USA Belief in a contin-
uum of symptom
experience
4 Bipolar disorder Vignette Likert
(1–5)
6 Cole etal. (2019) Online experiment n = 178;
mean
age = 38.01years;
35.4% male
MTurk sample USA Continuum and
categorical
beliefs
1 OCD Vignette Likert
(0–4)
7 Corrigan etal.
(2016)
Online experiment n = 598;
mean
age = 35.6years;
48.3% male
MTurk sample USA CBQ 16 Schizophrenia Vignette Likert
(1–6)
8 Dolphin etal.
(2017)
Online experiment n = 156;
mean
age = 16.25years;
48.7% male
Students Ireland Agreement with
continuum scale
1 Depression Vignette Likert
(1–6)
9 Fernandez etal.
(2022a)
Cross-sectional
(online)
n = 193;
mean
age = 17.5years;
21% male
Adolescents (com-
munity sample)
Australia Continuity beliefs;
fundamental dif-
ferences
4 Depression;
schizophrenia
Vignette Likert
(1–7)
10 Fernandez etal.
(2022b)
Cross-sectional
(online)
n = 271;
mean
age = 31.7years;
52% male
General population Australia Continuum and
categorical
beliefs
4 Schizophrenia Rating Likert
(1–4)
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5Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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Table 1 (continued)
No Study Design Sample Population Country Measure No. of items Examined disor-
ders
Method Response scale
11 Helmus etal.
(2019)
Intervention with
follow-up (paper–
pencil)
t1: n = 202;
mean
age = 45.5years;
34.7% male
t2: n = 131;
mean
age = 45.2years;
35.1% male
Mental health care
professionals
Netherlands CBQ 16 Schizophrenia Rating Likert
(1–6)
12 Makowski etal.
(2016)
Cross-sectional
(online)
n = 2006;
mean
age = 47.5years;
47.9% male
General population Germany Belief in a contin-
uum of symptom
experience
1 Depression;
schizophrenia
Vignette Likert
(1–4)
13 Makowski etal.
(2021)
Cross-sectional
(telephone
survey)
n = 1009;
18 to ≥ 65years;
49% male
General population Germany Continuity beliefs;
fundamental dif-
ferences
4 Depression Vignette Likert
(1–4)
14 Morris etal. (2020) Cross-sectional
(online)
n = 597;
mean
age = 37.21years;
52.9% male
General population United Kingdom PDBS 5 Alcohol use dis-
order
Vignette Likert
(1–5)
15 Norman etal.
(2008)
Cross-sectional
(paper–pencil)
n = 200;
mean
age = 21.5years;
45% male
Undergraduate
students
Canada Belief in a contin-
uum of symptom
experience
3 Depression;
schizophrenia
Vignette Likert
(1–5)
16 Norman etal.
(2010)
Repeated cross-
sectional (paper–
pencil)
Study 1 n = 200;
mean
age = 21.5years;
45% male
Study 2 n = 103;
mean
age = 55.7years;
50.5% male
Study 1: under-
graduate students
Study 2: commu-
nity service club
members
Canada Belief in a contin-
uum of symptom
experience
3 Depression;
schizophrenia
Vignette Likert
(1–5)
17 Paulus etal. (2015) Cross-sectional
(online)
n = 270;
mean
age = 26.8years;
19.6% male
Undergraduate
students
USA Belief in a contin-
uum of symptom
experience
1 Depression; social
anxiety disorder;
generalized anxi-
ety disorder
Vignette Severity rating
(0–8)
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6 Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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Table 1 (continued)
No Study Design Sample Population Country Measure No. of items Examined disor-
ders
Method Response scale
18 Schlier etal. (2016) Repeated cross-
sectional (online)
Study 1: n = 95;
mean age = 26.37;
50.5% male;
Study 2: n = 363;
mean
age = 27.4years;
34.7% male
Study 3: n = 229;
mean
age = 37.3years;
38.4% male
Study 1: online
sample
Study 2: online
sample
Study 3: general
population
Germany CBQ; CBQ-R 16; 14 Schizophrenia Rating Likert
(1–7)
19 Schlier etal. (2019) Online experiment n = 137;
mean
age = 27.8years;
28.5% male
Undergraduate
students + online
sample
Germany Perceived similar-
ity
4 Depression;
schizophrenia
Vignette Likert
(1–6)
20 Schomerus etal.
(2013)
Cross-sectional
(face to face,
paper–pencil)
n = 3642;
> 18years;
45.6% male
General population
(representative)
Germany Belief in a contin-
uum of symptom
experience
1 Depression; schiz-
ophrenia; alcohol
use disorder
Vignette Likert
(1–5)
21 Schomerus etal.
(2015)
Repeated cross-
sectional (online)
Study 1 n = 598;
Study 2 n = 806;
> 15years
General population
(representative)
Germany Belief in a contin-
uum of symptom
experience
1 Depression;
schizophrenia
Vignette Likert
(1–5)
22 Schomerus etal.
(2016)
Online experiment n = 1679;
> 15years;
49% male
General population
(representative)
Germany Continuity beliefs;
fundamental dif-
ferences
4 Depression;
schizophrenia
Vignette Likert
(1–5)
23 Schomerus etal.
(2022)
Repeated cross-
sectional (face-
to-face)
Study 1: n = 2455;
18 to ≥ 61years;
45.6% male;
Study 2: n = 3042;
18 to ≥ 61years;
47.2% male;
General population
(representative)
Germany Belief in a contin-
uum of symptom
experience
1 Depression;
schizophrenia
Vignette Likert
(1–5)
24 Seow etal. (2017) Cross-sectional
(online)
n = 500;
16.6% male
Undergraduate
students
Singapore Belief in a contin-
uum of symptom
experience
1 Depression; schiz-
ophrenia; alcohol
use disorder;
dementia, OCD
Vignette Likert
(1–5)
25 Speerforck etal.
(2019)
Cross-sectional
(telephone
survey)
n = 1008;
> 18years
General population
(representative)
Germany Belief in a contin-
uum of symptom
experience
1 ADHD Vignette Likert
(1–5)
26 Subrahamian etal.
(2017)
Cross-sectional
(online)
n = 3006;
18–65years;
50.9% male
General population
(representative)
Singapore Belief in a contin-
uum of symptom
experience
1 Depression; schiz-
ophrenia; alcohol
use disorder;
dementia, OCD
Vignette Likert
(1–5)
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7Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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Table 1 (continued)
No Study Design Sample Population Country Measure No. of items Examined disor-
ders
Method Response scale
27 Thibodeau & Peter-
son (2018)
Laboratory experi-
ment (paper–pen-
cil)
n = 135;
mean
age = 18.7years;
23.0% male
Undergraduate
students
USA Endorsement of
Continuum/Cat-
egorical beliefs
4 Schizophrenia Vignette Likert
(1–4)
28 Thibodeau (2017) Online experiment n = 308;
mean
age = 33.8years;
54.9% male
MTurk sample USA Continuum and
categorical
beliefs
1 Schizophrenia Vignette Likert
(1–5)
29 Thibodeau (2020) Online experiment n = 654;
mean
age = 29.6years;
39.1% male
MTurk sample USA Endorsement of
Continuum/Cat-
egorical beliefs
4 Depression Vignette Likert
(1–4)
30 Thibodeau, Shanks
etal. (2018)
Laboratory experi-
ment (paper–pen-
cil)
n = 69;
mean
age = 18.7years;
17.4% male
Undergraduate
students
USA Endorsement of
Continuum/Cat-
egorical beliefs
4 Schizophrenia Vignette Likert
(1–4)
31 Thoerel etal.
(2022)
Online experiment n = 725;
mean
age = 32.03years;
31.3% male
General population Germany General concept of
mental health
8 Eating disor-
ders (anorexia
nervosa, bulimia
nervosa, binge
eating disorder)
Vignette Likert
(1–5)
32 Violeau etal.
(2020)
Online experiment n = 565;
mean
age = 26.0years;
34.5% male;
General popula-
tion (mainly
undergraduate
students)
France QBCS (adapted
from the CBQ)
4 Schizophrenia Rating Likert
(1–7)
33 von dem Knese-
beck etal. (2015)
Repeated cross-
sectional (tel-
ephone survey)
Study 1: n = 650;
> 18years;
47.9% male
Study 2: n = 601;
> 18years;
48.1% male
General population
(representative)
Germany Belief in a contin-
uum of symptom
experience
1 Depression Vignette Likert
(1–5)
34 Wiesjahn etal.
(2014)
Cross-sectional
(online)
n = 120;
mean
age = 31.5years;
21.7% male
General population Germany CBQ 16 Schizophrenia Rating Likert
(1–6)
35 Wiesjahn etal.
(2016)
Online experiment n = 1189;
mean
age = 30.98years;
32.3% male
General population Germany CBQ 16 Schizophrenia Rating Likert
(1–6)
Notes. All measures were self-report measures and one-dimensional; CBQ Continuum Beliefs Questionnaire, PDBS Problem Drinking Belief Scale, OCD Obsessive Compulsive Disorder,
MTurk Amazon Mechanical Turk, a crowdsourcing platform, QBCS Questionnaire of Belief in a Continuum in Schizophrenia
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8 Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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disorder, and bipolar disorder. To elicit continuum beliefs,
27 out of 35 studies utilized vignettes, sometimes personal-
ized with names and/or gender. These vignettes consisted of
short descriptions of either a person with a specific disorder
or typical symptoms of said disorder based on its diagnostic
criteria according to DSM-IV or ICD-10. Eight studies used
a rating scale, for instance the Continuum Beliefs Question-
naire (CBQ), that measures continuum beliefs independent
of a vignette [52, 58, 64, 65]. All studies, except one [57],
used four-point to seven-point Likert scales as response
measures (i.e., agreement with statements about a person,
symptoms or a condition). The remaining study [57] asked
participants to rate the severity of presented vignettes on a
scale from 0 to 8 and provided a hint that experts perceived
a rating above four as clinically relevant.
Eighteen studies investigated general population samples,
with nine explicitly mentioning representativeness of their
sample (e.g., stratified sampling and weighted analysis).
However, studies rarely mentioned how representativeness
was achieved, for instance, via quota sampling or probabil-
ity sampling; therefore, this information is not included in
Table1. Seven studies examined (undergraduate) students,
seven used Amazon Mechanical Turk (MTurk) samples, and
three investigated adolescents [51, 70], or mental health pro-
fessionals [52].
Content ofcontinuum belief measures
Eleven different measures were used across studies, and all
were analyzes as one-dimensional measures. They ranged
from single-item measures for general continuum beliefs
[e.g., “Basically we are all sometimes like this person. It’s
just a question how pronounced this state is.“; 60] to illness-
specific scales with sixteen items [schizophrenia; 64], four
items [schizophrenia; 81] and five items [problem drink-
ing/addiction; 54]. Three measures, namely, Continuum
Beliefs Questionnaire (CBQ), Questionnaire of Belief in a
Continuum of Schizophrenia (QBCS), and Problem Drink-
ing Belief Scale (PDBS), received distinct labels, and other
measures did not, despite being used in multiple studies. The
single-item measure by Schomerus etal. [60], for instance,
was used or adapted by ten of the included studies [22, 48,
49, 51, 53, 59, 61–63, 74], one of which [49] performed
additional analyses with the same data set as the original
study [60]. Two studies [66, 67] also referred to one data
set. Most measures aim to assess beliefs in a continuum
of symptom experience (see Table1). However, a closer
look at the items used in these measures reveals three dif-
ferent aspects of continuum beliefs, namely, (1) continu-
ity of symptoms [e.g., "The transition between normal and
delusional thinking is fluent"; 58], (2) normality of mental
health problems [e.g., “To some extent, most persons will
experience problems that are similar to those of Anne”; 59],
and (3) normality of persons with mental health problems
[e.g., “Basically, we are all sometimes like this person”; 60].
Conceptually, the first continuum closely resembles the con-
tinuous understanding of mental health and mental illness,
as expressed, for instance, in the dimensional operationali-
zation of mental disorders in the DSM 5 or the psychosis
continuum [1, 4]. The second and third continua rely either
on a personal experience of symptoms or the identification
with a person with mental illness (i.e., a vignette). Both
refer to a norm of inclusivity (e.g., we are all like this per-
son, most people experience these symptoms) rather than a
continuum of symptoms to represent mental illness. They
are not necessarily linked to the nosological concept of an
illness but rather to its phenotype and prevalence (second
continuum) and the perceived similarity or lack of perceived
differentness regarding the vignette (third continuum). Per-
ceived differentness is often used as an indicator of stigma-
tizing attitudes, since it depicts the differentiation between
us and them, which is a core process of stigmatization [8].
The identified continua, exemplary items, and the assigned
studies are presented in Fig.2.
While most measures focus on only one or two aspects of
continuum beliefs, two measures represent all three aspects
of continuum beliefs, namely, the scale developed by Scho-
merus etal. [59] and the CBQ [64]. The former is generic
and vignette-based, the latter was specifically developed as
a rating scale for continuum beliefs regarding schizophrenia.
Despite their inclusion of all three aspects, both measures
were analyzed as one-dimensional scales, and the conceptual
differences between continua were not explored any further.
In addition, no study has empirically compared different
measures or operationalizations of continuum beliefs.
In the next step, we examined methodological quality,
psychometric properties, and utility (i.e., readability, cul-
tural translation, respondent burden) of continuum belief
measures across studies. Categories and ratings were based
on previous research [46, 47], and rated independently by
the first and third author. Differences were discussed and
resolved with the second author (see Table2).
Overall, most studies pointed to good readability, content
validity and low respondent burden. Criterion validity was
also very positive for most measures across studies. Cul-
tural translation of some measures was proven, for instance,
the adapted measure of Schomerus etal. [60]. All measures
were comparably short (1–16 items), which makes them
highly economical and efficient. Content validity and cri-
terion validity were also high for most studies, since meas-
ures were based on theoretical considerations, pretested and
validated, for example, via manipulation tests, and expert
consultations. Construct validity was mostly tested as dis-
criminant validity resulting in either low or negative correla-
tions between continuum beliefs and stigmatizing attitudes
in most studies except for one study on OCD [50]. Fewer
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9Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
1 3
studies reported (satisfactory) internal consistency (e.g.,
Cronbach’s alpha > 0.7), test–retest reliability was reported
in two studies [55, 56]. Floor or ceiling effects were not
explicitly reported in any of the included studies. Since all
measures were self-reports and few studies examined con-
tinuum beliefs at multiple timepoints to calculate test–retest
reliability, intra-rater reliability as well as inter-rater reliabil-
ity were also not reported. Responsiveness was very good, as
many studies used experimental designs and manipulation
checks to measure changes in continuum beliefs following
continuum belief interventions. None of the studies reported
known-groups validity (e.g., based on gender, age or type of
disorder) regarding continuum beliefs measures. As a sum-
mary, an overview of measures is provided in Table3.
Discussion
This systematic review summarizes and evaluates measures
of continuum beliefs of mental illness. The search identified
eleven different measures that ranged from single items to
multi-item scales. Most scales were generic, but some were
developed for specific disorders (i.e., schizophrenia, alcohol
use disorder). The measures seem to have high objectiv-
ity, since the instructions are clear, readability is high, and
they are easy to implement. Most measures also have high
validity due to their theory-based development, pretests, and
psychometric testing (see Table2). Yet, other psychometric
properties such as reliability (e.g., test–retest reliability) as
well as clinical utility have rarely been investigated beyond
initial piloting studies and reports of internal consistency.
Thus, more extensive psychometric studies are needed to test
factorial validity and measurement invariance, test–retest
reliability, and cross-cultural validity. The latter is particu-
larly important given cross-cultural differences in concep-
tualizing mental disorders that might influence continuum
beliefs [e.g., 82, 83].
Although some measures have been adapted to different
European, American, and Asian contexts [60], further com-
parative cross-cultural research is encouraged. Moreover, the
development, harmonization, and monitoring of continuum
belief measures should be connected to novel developments
in describing and diagnosing mental disorders. Paradigms
such as HiTOP [84] aim to provide an overarching hierar-
chy of psychopathology that pays respect to cross-cultural
differences and focuses on phenotypical similarities, thus
continuum belief measures could be developed and extended
in tandem.
The continuum belief measures were mostly implemented
in general population samples which supports their feasibil-
ity and applicability for epidemiological research. Epidemio-
logical mental health cohorts, for instance, could incorporate
Fig. 2 Three measured core aspects of continuum beliefs
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10 Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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Table 2 Psychometric properties of continuum belief measures in the included studies (n = 35)
Notes. Empty cells mean that no information was available/reported; Readability: + items available but lengthy; + + items available, short, and comprehensive; Cultural translation: + only available in English; + + available in English
and/or language(s) of the target population; Respondent burden: + over 60 items; + + under 60 items; Content validity: + theoretical foundation; + + theoretical foundation, and experts consulted; Criterion validity: + + Correlation coef-
ficient with external criteria calculated (e.g., other measures of continuum or categorical beliefs); Construct validity:—non-significant correlations with related (i.e., concurrent validity) and/or non-related constructs (i.e., discriminant
validity); + low correlations with related and/or non-related constructs; + + moderate to strong correlations with related and/or non-related constructs; Internal consistency:—mean Cronbach’s alpha below .70; + mean Cronbach’s alpha
between .70 and .80; + + mean Cronbach’s alpha at least equal to .80; Test–retest reliability: + + significant test–retest correlation across at least two different timepoints; Responsiveness:—unsuccessful manipulation check; + + suc-
cessful manipulation check (i.e., significant changes in continuum beliefs following a continuum belief intervention)
No. Study Readability Cultural transla-
tion
Respondent
burden
Content validity Criterion
validity
Construct
validity
Internal consist-
ency
Test–retest reli-
ability
Responsiveness
1 Angermeyer etal. (2015) + + + + + + + +
2 Bahlmann etal. (2015) + + + + + +
3 Buckwitz etal. (2021) + + + + + + + + + + +
4 Buckwitz etal. (2022) + + + + + + + + + + +
5 Cassidy etal. (2020) + + + + + + + + +
6 Cole etal. (2019) + + + + + + - + +
7 Corrigan etal. (2016) + + + + + + +
8 Dolphin etal. (2017) + + + + + + + +
9 Fernandez etal. (2022a) + + + + + + + + -
10 Fernandez etal. (2022b) + + + + + - + +
11 Helmus etal. (2019) + + + + + + + + +
12 Makowski etal. (2016) + + + + + + + + + +
13 Makowski etal. (2021) + + + + + -
14 Morris etal. (2020) + + + -
15 Norman etal. (2008) + + + + + + + + + + + + +
16 Norman etal. (2010) + + + + + + + + + +
17 Paulus etal. (2015) + + + + +
18 Schlier etal. (2016) + + + + + + + + + + + +
19 Schlier etal. (2019) + + + + + + + +
20 Schomerus etal. (2013) + + + + + + + + +
21 Schomerus etal. (2015) + + + + +
22 Schomerus etal. (2016) + + + + + + + + + + + + +
23 Schomerus etal. (2022) + + + + + + + + +
24 Seow etal. (2017) + + + + + + + + +
25 Speerforck etal. (2019) + + + + + + + + + + + +
26 Subrahamian etal. (2017) + + + + + + + + + +
27 Thibodeau & Peterson (2018) + + + + + + + + +
28 Thibodeau (2017) + + + + + + + + + +
29 Thibodeau (2020) + + + + + + + + + + +
30 Thibodeau, Shanks etal. (2018) + + + + + + + + +
31 Thoerel etal. (2022) + + + + + + + + + +
32 Violeau etal. (2020) + + + + + + + -
33 von dem Knesebeck etal. (2015) + + + + + + +
34 Wiesjahn etal. (2014) + + + + + + + + + + + +
35 Wiesjahn etal. (2016) + + + + + + + + + + + + +
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11Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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these measures to assess not only stigmatizing attitudes but
also continuum beliefs. Similarly, anti-stigma campaigns
could include continuum belief measures to measure effi-
cacy concerning public health impact, due to mostly robust
negative associations between continuum beliefs and stig-
matizing attitudes [36]. However, in some studies [e.g., 50,
81], this association was not significant; the continuum
belief intervention even lead to an increase in self-stigma
(i.e., being weird/unpredictable is typical of me) in one study
[81]. The authors [81] argue that this type of non-threaten-
ing self-stigma (e.g., weird as opposed to dangerous) is an
expression of increasing perceived similarities to the target
group thus strengthening shared social identity. However, it
is unclear how this affects persons with more severe symp-
toms and perceived similarity with more threatening attrib-
utes (e.g., dangerous). Potentially, continuum belief inter-
ventions could exacerbate group differences in samples with
more severe symptoms, because vignettes of disorders with
mild to moderate severity (as used in continuum belief meas-
ures) highlight the discrepancy between normal functioning
and their personal experience. For example, in a study by
Thibodeau and Peterson [78], the continuum belief interven-
tion increased fear. This conclusion is merely hypothetical,
though because of a lack of studies with a varying severity
of symptoms and mental disorders.
Overall, more studies with clinical samples and men-
tal health professionals are needed to assess clinical util-
ity and practicability. One study with persons with at risk
alcohol use [54] provided tentative evidence that promot-
ing continuum beliefs might increase problem recognition.
Problem recognition is an important predictor of treatment
motivation following the transtheoretical model of health
behavior change [85, 86], and it can lead to lower drop-out
rates, which is very promising for this field [87]. Therefore,
the function of continuum beliefs in treatment processes
needs to be studied more closely. This is also true for more
diverse populations (e.g., children and adolescents, older
adults). One study with adolescents showed good psycho-
metric properties of continuum belief measures [51], but
more research is necessary to confirm these findings. Since
several studies used random online samples (gathered via
MTurk), their results should also be interpreted with caution
when thinking about adapting scales to applied contexts,
since there is an ongoing debate about data quality and valid-
ity of MTurk data and similar online panels and services
compared to pragmatic, and community samples [88–90].
Hence, multi-group comparisons of samples from different
providers and sources are recommended.
Furthermore, the conceptualization of continuum beliefs
needs to be examined. The CBQ, the PDBS, and the QBCS
were developed for specific disorders, which is why they
can refer to disorder-specific symptoms without including
vignettes or descriptions of mental disorders as a frame
of reference. Consequently, other studies did not need to
adapt or pretest additional materials. These scales could also
directly describe a disorder-specific continuum of symptoms
(e.g., the psychosis continuum; [4]) as an indicator of mental
stress leading to mental illness, which is in line with the
approach of normalization proposed by Angermeyer und
Schulze [21]. Vignette-based studies with more generic
scales, on the other hand, were more flexible and allow
direct comparisons of beliefs regarding different disorders—
which lends credibility to the idea of an underlying concept
of continuity or dimension of mental health and illness. This
way of thinking corresponds to current positive psychologi-
cal approaches, such as the dual continuum model of men-
tal health [43, 44], and the HiTOP model with its focus on
phenotypes rather than diagnostic labels or categories [84].
This more generic approach, however, also requires
validated vignettes to assess continuum beliefs. This is
challenging for multiple reasons: First, the included stud-
ies used different vignettes which could have biased the
results. Second, most studies controlled for confounding
influences by either presenting no gender or name or ran-
domizing gendered vignettes. However, these vignettes
still required participants to imagine the person and their
symptoms, which requires sufficient perceived realism of
each vignette and consensus regarding the described experi-
ence (e.g., of a depressive episode) [91]. Therefore, future
research should compare continuum beliefs across different
vignettes. Third, other aspects such as age or ethnicity of
the presented or imagined person were not controlled and
might have additional influence on continuum beliefs [92].
Hence, future studies should examine the differential impact
of different disorder-specific vignettes on multiple measures
of continuum beliefs. These vignettes could also be tested
or constructed based on population assessments, similar to
the measure of Paulus etal. [57] In their study, they asked
participants to rate the severity of different symptoms and
behaviors ranging from healthy to clinically relevant. While
this is closely connected to a diagnostic approach (e.g., in
psychotherapeutic training), it also provides the opportunity
to customize (sub-)clinical vignettes of specific disorders
concerning type and intensity of symptoms and assess sub-
sequent ratings to examine the extent of continuum beliefs.
In this sense, future research could build upon scale-based
measures, such as the CBQ that requires similar assessments
(e.g., regarding hallucinations) via Likert scales.
Finally, different operationalizations of continuum beliefs
are also a promising avenue for future research, similar to
the area of health literacy, where multiple objective tests and
subjective self-reports are state of the art [93, 94]. While the
identified measures captured between one and three aspects
of the continuum (see Fig.2), certain aspects were rarely
examined, for example, the categorical v continuous con-
ceptualization of mental illness [2, 3]. Items measuring this
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12 Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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Table 3 Overview of eleven measures of continuum beliefs (plus a revised version of the Continuum Beliefs Questionnaire) including their origin, number of items, assessment method, and the
dimensions of continuum reflected with each measure as well as examined disorders
Measure Origin No. of items Method Country Type of continuum Examined disorders
Belief in a continuum of symp-
tom experience
Schomerus etal. (2013) 1 Vignette France; Germany; Singapore;
Ireland
Normality of persons with
mental health problems
Depression; schizophrenia;
alcohol use disorder; dementia,
obsessive–compulsive disorder;
attention deficit hyperactivity
disorder
Continuity beliefs Schomerus etal. (2016) 4 Vignette Germany Continuity of symptoms
Normality of mental health
problems
Normality of persons with
mental health problems
Depression; schizophrenia
Continuum beliefs Thibodeau (2017) 1 Vignette U SA Normality of mental health
problems
Schizophrenia; obsessive–com-
pulsive disorder
Endorsement of continuum
beliefs
Thibodeau, Shanks etal. (2018) 4 Vignette USA Continuity of symptoms Schizophrenia
Continuum Beliefs Question-
naire
Wiesjahn etal. (2014) 16 Rating Germany; USA; Netherlands Continuity of symptoms
Normality of mental health
problems
Normality of persons with
mental health problems
Schizophrenia
Continuum Beliefs Question-
naire-revised
Schlier etal. (2016) 14; 16 Rating Germany Continuity of symptoms
Normality of mental health
problems
Normality of persons with
mental health problems
Schizophrenia
Belief in a continuum of symp-
tom experience
Norman etal. (2008) 3; 4 Vignette Canada; USA Normality of mental health
problems
Normality of persons with
mental health problems
Depression; schizophrenia; bipo-
lar disorder
Perceived similarity Schlier etal. (2019) 4 Vignette Germany Normality of persons with
mental health problems
Depression; schizophrenia
Belief in a continuum of symp-
tom experience
Paulus etal. (2015) 1 Vignette USA Continuity of symptoms Depression; social anxiety
disorder; generalized anxiety
disorder
Problem Drinking Belief Scale Morris etal. (2020) 5 Vignette USA Continuity of symptoms Alcohol use disorder
General concept of mental
health
Thoerel etal. (2022) 8 Vignette Germany Normality of mental health
problems
Normality of persons with
mental health problems
Eating disorders
Questionnaire of Belief in a
Continuum in Schizophrenia
Violeau etal. (2020) 4 Rating France Continuity of symptoms
Normality of mental health
problems
Schizophrenia
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13Social Psychiatry and Psychiatric Epidemiology (2023) 58:1–16
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nosological concept were included in the development of the
CBQ, but they were eventually excluded from the final meas-
ure [64]. It might be beneficial to compare measures of such
conceptual beliefs with continuum beliefs measures, and
compare multiple measures of continuum beliefs, to assess
similarities and differences and examine their responsive-
ness in future interventional studies. Nevertheless, it should
also be added that a more conceptual measure of continuum
beliefs requires a more abstract assessment of nosological
concepts of illness and health, which might be rather difficult
for laypersons, meaning population samples without previ-
ous education about this issue.
In sum, when choosing a measure of continuum beliefs, a
researcher needs to think about the population (e.g., a sam-
ple with clinical depression vis-à-vis a healthy population
sample), the context (e.g., disorder-specific versus transdi-
agnostic assessments), the method (e.g., rating scales versus
vignettes), and the overall aim of the study (e.g., compar-
ing attitudes across groups or disorders versus examining
predictive utility or validity of continuum beliefs). In an
epidemiological study of depression-related attitudes in
the population, a disorder-specific measure using vignettes
might be most appropriate, whereas a comparative study of
continuum beliefs across different disorders might benefit
from a short, generic measure that has a low respondent
burden and allows for transdiagnostic comparisons. While
our review shows that some types of measures have received
more attention than others so far, the usefulness and merit of
each measure strongly depends on the context of investiga-
tion. This review provides a framework for decision-making
and further research in continuum beliefs of mental illness.
The review is not without limitations. The search was
limited to three data bases, and preregistered search cri-
teria (e.g., regarding search terms, language) as well as
peer-reviewed literature, which might have neglected grey
literature and other studies that could not be identified by
the initial search. The review focused on continuum beliefs
of mental illness, while previous literature defined different
continua (e.g., continuum of care, dual continua model) that
might be associated with continuum beliefs. For instance,
the continuum of care assumes different needs and respon-
sibilities for different stages of an illness, such as prevention,
acute treatment, or recovery [95]. These stages are associ-
ated with different levels of severity of an illness, which
might serve as a reference for assessing continuum beliefs.
Similarly, the dual continua model assumes parallel continua
of mental well-being and mental health/illness. It is unclear
how different constellations of well-being and mental health
(e.g., flourishing) are associated with continuum beliefs. The
study used established ratings of methodological quality and
it reported results in accordance with the PRISMA state-
ment, but it did not examine risk of bias or use different
rating systems of measures. This could be the focus of future
work. Despite its weaknesses, however, this review identi-
fied several measurement instruments of continuum beliefs
with applications in multiple cultural contexts, and initial
evidence of good validity, and applicability in general popu-
lation samples. Hence, the potential of continuum beliefs
regarding public mental health and the economic modes of
assessment are quite promising.
Acknowledgements This review was supported by the German
Research Foundation (DFG; GS, grant number SCHO-1337/4-2; SiS,
grant number SCHM-2683/4-2). The DFG did not have any role in
study development, analysis, or interpretation of the data. The funding
body was not involved in writing this report nor the decision to submit
it for publication.
Author contributions Conceptualization, ST and HoM.; methodology,
ST, SaS, TG, and LJP.; software, ST; validation, ST, SaS, TG, TM, and
HoM; formal analysis, ST, SaS, and TG; investigation, ST, SaS, TG,
and LJP; resources, ST, SaS, TG, and LJP; data curation, ST, SaS, TG,
and LJP; writing—original draft, ST; writing—review and editing, TM,
HoM, LJP, GS, and SiS; visualization, ST; supervision, ST, TG, and
HoM; supervision, ST, HoM, GS, and SiS; project administration, ST,
HoM, GS, and SiS; funding acquisition, GS and SiS. All authors have
read and approved the final version of the manuscript.
Funding Open Access funding enabled and organized by Projekt
DEAL.
Data availability statement Data sharing is not applicable to this article
as no new data were created or analyzed in this study.
Declarations
Conflict of interests All authors declare that they have no conflicts of
interest.
Ethical standards Not applicable.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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